**1. Introduction**

Despite being an established cost effective public health strategy for improving child survival, each year millions of children in low- and middle-income countries (LMICs) do not receive

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the full series of vaccines on their national routine immunization schedule [1, 2]. In Pakistan, over 50% of deaths in post-neonatal children are attributable to pneumonia, diarrhea, or meningitis, which can be prevented through vaccination [3]. The Government of Pakistan initiated the Expanded Program on Immunization (EPI) in 1978, and gradually introduced all requisite antigens, with the recent addition of Rota virus [4]. WHO recommends immunization coverage of 90% at the national level and at least 80% for every district [5]. Pakistan's immunization indicators have improved since the program's inception; however, recent data from 2012 to 2013 recorded merely 54% full immunization coverage for children age 12–23 months (**Figure 1**) [6].

Vaccine-specific coverage starting from BCG coverage at 85% falls to 61% for measles (**Figure 1**). In addition, there is a large drop out seen from the first two doses of polio (90.2%) and DPT (76.8%) to third doses of the same vaccines (82% and 62.5% respectively). Vaccine coverage drops with birth order; first child coverage is 64% while only 39% of children born in order 6 or more are fully covered. There are significant regional variations with the Islamabad Capital Territory having the highest percentage (74%), followed by the provinces of Punjab (66%) and Khyber Pakhtunkhwa (53%); whereas immunization coverage is lowest in Sindh province (29%) and Baluchistan province (16%). There are obvious differences in immunization coverage between children of women with no education (40%) and children of literate mothers (74%). Children from households in the highest wealth quintile are much more likely to be fully immunized (75%) as compared to those in the lowest quintile (23%) [6]. In Punjab, the situation seems to be deteriorating (**Figure 2**) with the percentage of fully immunized children age 12–23 months dropping to be 56% in 2014 [7], whereas Sindh showed improvement with full immunization coverage increasing to 35% in 2014 [8].

Another national survey from 2014 to 2015 captured a significant gap in the percentage of fully immunized children between rural (56%) and urban (70%) areas. The provincial differences demonstrate similar disparity. The data for urban/rural differences by province were in Sindh (62/33%), Baluchistan (48/20%), Khyber Pakhtunkhwa (74/54%), and Punjab (75/65%). Punjab had the highest immunization rate (70%) followed by Khyber Pakhtunkhwa (58%) and Sindh (45%). Baluchistan, which is the most deprived area, had the lowest coverage with

**Figure 2.** Vaccination coverage in 2014 for children age 12–23 months in Punjab and Sindh provinces. Multiple Indicator

Implementation of the Expanded Program on Immunization (EPI): Understanding the Enablers…

http://dx.doi.org/10.5772/intechopen.78676

69

Given this state of affairs, it is evident that there is a need to take stock, particularly to understand the health system wide enablers as well as the barriers that could influence progress. And thereon develop strategies to either overcome or capitalize on these factors to optimize

This chapter aims at bridging the information gaps about system-level barriers that currently are impeding the optimal delivery of immunization services to the children of Pakistan. We employed the basic tenets of WHO's health systems strengthening framework i.e. governance, financing, service delivery, human resource, information systems, and essential drugs, supplies and technologies [10], and the Sallis' socio-ecological model which helps in studying the community's perceptions and behaviors [11]. Hence, this study explored various pillars of the immunization program in Pakistan from both the service delivery and the demand side perspective. We conducted a detailed literature review to document what has been published already about this topic, identified barriers and levers of EPI implementation, and then developed a set of recommendations. Using MeSH terms and key words (Immunization; Child health; Health system; Pakistan), relevant peer reviewed articles were accessed using PubMed and Google Scholar. Other reports and documents were accessed from the websites of EPI Pakistan and UN agencies. Salient areas emerging from the literature review were cataloged

only 27% of children fully immunized [9].

under the building blocks of the health system.

performance of the EPI program.

cluster survey 2014.

**Figure 1.** Trends in immunization coverage among children age 12–23 months. Pakistan Demographic & Health Survey 2012–2013.

Implementation of the Expanded Program on Immunization (EPI): Understanding the Enablers… http://dx.doi.org/10.5772/intechopen.78676 69

the full series of vaccines on their national routine immunization schedule [1, 2]. In Pakistan, over 50% of deaths in post-neonatal children are attributable to pneumonia, diarrhea, or meningitis, which can be prevented through vaccination [3]. The Government of Pakistan initiated the Expanded Program on Immunization (EPI) in 1978, and gradually introduced all requisite antigens, with the recent addition of Rota virus [4]. WHO recommends immunization coverage of 90% at the national level and at least 80% for every district [5]. Pakistan's immunization indicators have improved since the program's inception; however, recent data from 2012 to 2013 recorded merely 54% full immunization coverage for children age 12–23 months

Vaccine-specific coverage starting from BCG coverage at 85% falls to 61% for measles (**Figure 1**). In addition, there is a large drop out seen from the first two doses of polio (90.2%) and DPT (76.8%) to third doses of the same vaccines (82% and 62.5% respectively). Vaccine coverage drops with birth order; first child coverage is 64% while only 39% of children born in order 6 or more are fully covered. There are significant regional variations with the Islamabad Capital Territory having the highest percentage (74%), followed by the provinces of Punjab (66%) and Khyber Pakhtunkhwa (53%); whereas immunization coverage is lowest in Sindh province (29%) and Baluchistan province (16%). There are obvious differences in immunization coverage between children of women with no education (40%) and children of literate mothers (74%). Children from households in the highest wealth quintile are much more likely to be fully immunized (75%) as compared to those in the lowest quintile (23%) [6]. In Punjab, the situation seems to be deteriorating (**Figure 2**) with the percentage of fully immunized children age 12–23 months dropping to be 56% in 2014 [7], whereas Sindh showed improve-

Another national survey from 2014 to 2015 captured a significant gap in the percentage of fully immunized children between rural (56%) and urban (70%) areas. The provincial differences demonstrate similar disparity. The data for urban/rural differences by province were in

**Figure 1.** Trends in immunization coverage among children age 12–23 months. Pakistan Demographic & Health Survey

ment with full immunization coverage increasing to 35% in 2014 [8].

(**Figure 1**) [6].

68 Immunization - Vaccine Adjuvant Delivery System and Strategies

2012–2013.

**Figure 2.** Vaccination coverage in 2014 for children age 12–23 months in Punjab and Sindh provinces. Multiple Indicator cluster survey 2014.

Sindh (62/33%), Baluchistan (48/20%), Khyber Pakhtunkhwa (74/54%), and Punjab (75/65%). Punjab had the highest immunization rate (70%) followed by Khyber Pakhtunkhwa (58%) and Sindh (45%). Baluchistan, which is the most deprived area, had the lowest coverage with only 27% of children fully immunized [9].

Given this state of affairs, it is evident that there is a need to take stock, particularly to understand the health system wide enablers as well as the barriers that could influence progress. And thereon develop strategies to either overcome or capitalize on these factors to optimize performance of the EPI program.

This chapter aims at bridging the information gaps about system-level barriers that currently are impeding the optimal delivery of immunization services to the children of Pakistan. We employed the basic tenets of WHO's health systems strengthening framework i.e. governance, financing, service delivery, human resource, information systems, and essential drugs, supplies and technologies [10], and the Sallis' socio-ecological model which helps in studying the community's perceptions and behaviors [11]. Hence, this study explored various pillars of the immunization program in Pakistan from both the service delivery and the demand side perspective. We conducted a detailed literature review to document what has been published already about this topic, identified barriers and levers of EPI implementation, and then developed a set of recommendations. Using MeSH terms and key words (Immunization; Child health; Health system; Pakistan), relevant peer reviewed articles were accessed using PubMed and Google Scholar. Other reports and documents were accessed from the websites of EPI Pakistan and UN agencies. Salient areas emerging from the literature review were cataloged under the building blocks of the health system.
